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Plumbing & Mechanical Systems ProfessionalsJoint Contractor License & Registration ApplicationMail completed application and fee to:Plumbing & Mechanical Systems Board – IDPH321 E. 12th St.Des Moines, IA 50319Part 1. Business Information.Contractor License Number or NEWBusiness NameFull Name of Business Owner(First Middle Last)Business EmailOwner Email if differentBusiness PhoneMobile NumberFaxPermanent PhysicalBusiness AddressCityStateZipMailing Address,If DifferentCityStateZipPlease check which address to display on the board website: PermanentFederal Tax ID# (FEIN)or SSN if sole proprietor MailingNumber Provided SSN of Owner or Business FEINPrivacy Act Notice: Disclosure of your Social Security Number is required by 42 U.S.C. § 666(a)(13), Iowa Code §252J.8(1),§261.126(1), and §272D.8(1). The number will be used in connection with the collection of child support obligations, college studentloan obligations, and debts owed to the state of Iowa, and as an internal means to accurately identify licensees, and may also beshared with taxing authorities as allowed by law including Iowa Code § 421.18.Business Type⃝ Corporation⃝ Firm/Entity⃝ Partnership ⃝ Sole Proprietor/Individual OwnershipPart 2. Screening Questions.The following questions must be answered by all applicants. If you answer “Yes” to any questions below (1) attacha signed letter of explanation providing the details of the incident, including date(s), location(s), status, reason, etc., (2)attach a copy of any court ordered evaluations, showing completion & recommendations, and (3) attach a copy of allofficial court documents regarding your conviction/malpractice suit, including final disposition or settlement. You mustanswer “Yes” even when a conviction or judgment has been deferred or expunged from your record.1. Has any state or other jurisdiction of the United States or any other nation ever limited, restricted,warned, censured, placed on probation, suspended, revoked, or otherwise disciplined a professionallicense, permit, registration, or certification issued to you or the organization?⃝ Yes⃝ No2. Have there ever been judgments or settlements paid on your behalf or the organization’sbehalf as a result of a professional liability case?⃝ Yes⃝ No3. Have you or the organization ever had a license, permit, registration, or certificationdenied, suspended, revoked, or otherwise disciplined by a certification body?⃝ Yes⃝ NoIf you answered Yes to any of the above questions please provide a detailed explanation. Attach additional sheets,signed by you, as necessary.Contractor App (4/2020)Page 1

The following additional questions must be answered by sole proprietor applicants only. If you answer “Yes” toany questions below (1) attach a signed letter of explanation providing the details of the incident, including date(s),location(s), status, etc., (2) attach a copy of any court ordered evaluations, including any recommendations, & (3) attacha copy of all official court documents regarding your conviction/malpractice suit, including final disposition or settlement.You must answer “Yes” even when a conviction or judgment has been deferred or expunged from your record.4. Do you have a medical condition, which in any way currently impairs or limits your ability to performthe duties of this profession? Medical Condition: means any physiological, mental, or psychologicalcondition, impairment, or disorder, including drug addiction and alcoholism?⃝ Yes⃝ No5. Have you, within the past 5 years, engaged in the illegal or improper use of drugs or other chemical⃝ Yes⃝ Nosubstances?6. Have you ever been convicted of, or entered a plea of no contest to a misdemeanor or felony⃝ Yes⃝ Nocrime? (Other than minor traffic violations with fines under 250). You must answer yes if the courtexpunged the matter or the court deferred judgment.)If you answered Yes to any of the questions 3 to 6, please provide a detailed explanation. Attach additional sheets, signedby you, as necessary.Part 3. Contractor Registration Details. Pursuant to Iowa Code chapter 91C a contractor must alsomaintain registration as a contractor with the Iowa Division of Labor and renew registration at the time oflicense renewal. These requirements are separate from the requirements for contractor licensure with theboard. The information provided will be transmitted to the Iowa Division of Labor for your contractorregistration. The Division of Labor may contact you if they have questions about your registration details.Are you already registered as a contractor with the Iowa Division of Labor?⃝ Yes⃝ NoIf yes, existing Iowa Contractor Registration Number (begins with a C):Unemployment Insurance (UI) Account Number:Do you have an out of state bond on file?⃝ Yes⃝ NoAre you requesting a fee exemption from the Division of Labor registration fee?⃝ Yes⃝ NoIf you select yes, you must attach a notarized copy of the Fee Exemption Form (Supplement Form 2). Note the feeexemption only applies to the IWD registration fee and NOT the Plumbing & Mechanical Systems Board contractor licensefee. To qualify for the fee exemption, you must be able to answer Yes to each of the following questions:I do not pay more than 2,000 per year to employ other persons (do not include yourself) inthe business of construction.⃝ Yes⃝ NoI never perform construction work with or for other contractors working in the “same phase ofconstruction” at the job site. The “same phase of construction” is defined as the same typeof work, such as masonry, stonework, electrical work or concrete work, etc.If applicable, I have enclosed a list of all current employees and a list of all employees whohave worked for me in the past 12 months and the amount paid to each employee.⃝ Yes⃝ No⃝ Yes⃝ NoSelect your Worker’s Compensation Compliance Method:⃝ I am insured – enclose copy of Workers’ Compensation Insurance certificate listing the Iowa Division ofLabor, 150 Des Moines St, Des Moines, IA 50309-1836 as a certificate holder.⃝ I am self-insured – enclose copy of Certificate of Relief issued by the Iowa Insurance Division.⃝ I have no employees.Contractor App (4/2020)Page 2

Part 4. Master of Record Information. Identify the trade(s) in which work is performed and provide the name ofthe Master of Record for each trade. Only one Master of Record will be accepted per trade. Attach and complete theMaster of Record Certification Form for each person listed. (Supplement Form 1)Trade DisciplineMaster of Record NameIowa Master License #:⃝ Plumbing⃝ HVAC/R⃝ Hydronics⃝ MechanicalPart 5. Applicant Signature & Affidavit. Please read carefully. You must sign & date for yourapplication to be processed.I certify that I am either (1) a sole proprietor or (2) a business owner of the applicant and am authorized tosubmit this contractor license application and contractor registration application on behalf of thefirm/entity.I certify that I have read all requirements pursuant to Iowa Code chapter 105 & Iowa Administrative Codepertaining to contractor licensing, including 641—23.2(105), 641—23.3(105), and 641 IAC Chapter 32.I certify that I have carefully read the questions on this application and have answered them completelyand truthfully. I declare under penalty of perjury that the answers, and all other statements or informationsubmitted by me in this application are true and correct. If it is determined at any time that I have providedmisleading or false information on, or in support of, this application, I understand that the applicant’slicense (or mine if applicable) may be subject to disciplinary action, license revocation and criminalprosecution.I also understand that this application is a public record in accordance with Iowa Code chapter 22 andthat application information is public information, subject to the exceptions contained in Iowa law. Finally,in submitting this application, I consent on behalf of the applicant/firm/entity to any reasonable inquiry,including a licensing audit that may be necessary, to verify the information I have provided on, or inconjunction with, this application.An applicant is responsible for the accuracy of the information provided, regardless of who completes andsubmits the applicant's application. Incomplete applications shall be considered invalid after 90 days andshall be destroyed. All fees are nonrefundable.Printed Name of Business Owner:Signature of Business Owner:Date of Signature:Contractor App (4/2020)Page 3

Master of Record Certification Form (Supplemental Form 1)Contractor applications must have a Master of Record Certification form for each master of record named for thebusiness. The purpose of this form is to ensure that the Master of Record named by the business agrees to serve as theMaster of Record (MOR) for the business and understands their responsibilities. If you have more than one MOR, copythis form and submit a separate form for each individual.Business Name:Master of Record Name:License #:“Master of record” means an individual possessing an active master license under Iowa Code chapter 105 who shall beresponsible for the following:o Proper designing, installing, and repairing of plumbing, mechanical, HVAC-refrigeration, sheet metal, or hydronicsystems;o Being actively in charge of the plumbing, mechanical, HVAC-refrigeration, sheet metal, or hydronic work of thecontractor.I hereby, agree to be the Master of Record, as defined above, for the contractor named on this form, in thefollowing trade disciplines:⃝ Plumbing⃝ HVAC/R⃝ Hydronics⃝ MechanicalA master may only be a master of record for one contractor in any particular discipline at any one time, except that acontractor or a master may seek prior board approval to serve as the master of record for more than one contractor in aparticular discipline. An individual who possesses master licenses in multiple disciplines may be a master of record formultiple contractors so long as the individual is only a master of record for one contractor in any particular discipline atone time. Without prior board approval, a contractor shall not knowingly utilize a master licensee to meet thisrequirement if the master licensee is simultaneously associated with another contractor in that discipline.⃝ Yes ⃝ No Are you currently serving as Master of Record for another licensed contractor in plumbing, HVAC/R,hydronics, or mechanical systems?If yes, provide name of business and specify the trade disciplines in which you are serving as master of record:Supervision. A master who superintends the design, installation, or repair of plumbing, mechanical, HVAC-refrigeration,or hydronic systems shall be available to supervise journeypersons or apprentices as needed and may only provide suchsupervision in the discipline or disciplines in which the master is licensed. A master shall not knowingly superviseunlicensed persons who perform work covered under Iowa Code chapter 105 for which a board-issued license isrequired.A helper for which a license is not required may only perform general manual labor activities under the supervision of ajourneyperson or master. A licensee who utilizes the services of an unlicensed helper shall be responsible for the workperformed by the helper and shall ensure that such work conforms to the minimum standard of acceptable and prevailingpractice.Master of Record Signature & Affidavit. Please read carefully, sign & date.I certify that I have read and understood the requirements to serve as Master of Record for the contractor namedabove. I hereby agree to be Master of Record for this contractor in the trade discipline(s) specified.I certify that I understand the requirements for providing supervision and agree that I will not knowingly superviseunlicensed persons who perform work covered under Iowa Code chapter 105 for which a board-issued license isrequired.I understand I must notify the board within 30 days in the event I am no longer serving as master of record for thiscontractor. I understand that violation of any of these requirements may subject me to disciplinary action against mymaster license, up to and including license revocation.Signature:Contractor App (4/2020)DatePage 4

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IOWAKim Reynolds, Governor AdamGregg, Lt. GovernorRod A. Roberts, Labor CommissionerDEVELOPMENTContractor Registration #:Division of LaborBusiness Name:FEE EXEMPTION FORMCheck all that apply to your current situation:I am a self-employed contractor.I do not pay more than 2,000.00 per year to employ other people in the business (do not include yourself)in the business of construction.I never perform construction work with or for other contractors working in the “same phase of construction.”The “same phase of construction” is defined as the same type of work, such as masonry, stonework,electrical work or concrete work, etc.If applicable, I have enclosed a list of all current employees and a list of all employees who have worked forme in the past 12 months and the amount paid to each employee.If all of the statements are true, you may qualify for an exemption from the 50.00 yearly contractor registration fee. Ifyour business changes so that you no longer meet the fee exemption requirements, you must immediately forwardthe fee to the Iowa Division of Labor. Attach an additional sheet for employee data, if necessary. A new feeexemption form is required yearly along with renewing your contractor registration.Please have a notary public ready to witness when signing this fee exemption form. Attach this form to yourapplication and forward to the Division of Labor.To be filled out only by a notary publicSTATE OFCOUNTY OFSigned and sworn to (or affirmed) before me on thisday of, 20By(printed contractor’s name)NOTARY PUBLIC in and for the State ofMy commission expiresContractor’s printed nameContractor’s signatureDateIowa Division of Labor Contractor Registration150 Des Moines Street, Des Moines, IA 50309Phone: 515-242-5871 Fax: 515-725-2427 www.iowacontractor.gov contractor.registration@iwd.iowa.govEqual Opportunity Employer/ProgramAuxiliary aids and services are available upon request to individuals with disabilities.For deaf and hard of hearing, use Relay 711.

Iowa Division of LaborContractorRegistration 150 DesMoines StreetDes Moines, IA 503091836 Phone: 515-2425871Fax: w.iowacontractor.govAddRemoval/Additional Owner,Officer, Partner orMember FormBusiness Name:RemoveOwner, officer, partner or member nameEmail addressPhone numberAddressCityStateOwner, officer, partner or member nameEmail addressPhone numberAddressCityStateOwner, officer, partner or member nameEmail addressPhone numberAddressCityStateOwner, officer, partner or member nameEmail addressPhone numberAddressCityStateOwner, officer, partner or member nameEmail addressPhone veZipRemoveZipRemoveZipI certify that the information on this form and the attachments is true and accurate to the best of my knowledge.Name of individual completing formSignatureContractor registration #Email addressPhone numberDate500-01001.22.2020Suppmental Form 3

FOR OFFICE USE ONLYContractor RegistrationIowa Division of Labor1000 East Grand AvenueDes Moines, IA 50319-0209Phone: 515-242-5871Fax: tration number:Date received:OUT-OF-STATE CONTRACTOR BOND FORMBond Number:Effective Bond Date:THATof(Principal)(Mailing address), and(City and State)(Surety)are held and firmly bound unto the State of Iowa, Division of Labor as the holder in the penal sum oftwenty-five thousand dollars ( 25,000) lawful money of the United States, to the payment of which sum,the Principal and Surety firmly bind themselves, their heirs, executors, successors, assigns andadministrators, jointly and severally.This obligation arises because the Principal is an out-of-state contractor desiring to perform constructionwork in the State of Iowa. Iowa Code Chapter 91C requires the Principal file this bond.The Principal shall pay all taxes, including contributions due under the unemployment compensationinsurance system, penalties, interest and related fees which may accrue to the State of Iowa, due to thePrincipal’s work in Iowa. This bond may be renewed by a Continuation Certificate.This bond shall be continuous in nature until cancelled by the Surety with not less than thirty (30) days’written notice to the Principal and to the Iowa Division of Labor, but shall not exceed the one (1) yearstatutory period. This bond shall run concurrently with the annual term of the Principal’s out-of-statecontractor registration pursuant to Iowa Code Chapter 91C.The obligation of this bond shall be operative until released in the manner provided in Iowa CodeChapter 91C.Executed thisday of, 20.Principal (signature)Surety (signature)Lrco 600-2.03.09.15600-0201.12.2016

Iowa Plumbing and Mechanical Systems Board Iowa Dept. of Public Health 321 E 12th Street Des Moines, Iowa 50319 An application is not considered complete and will not be processed until all items have been submitted, including fees. Please allow up to four weeks for processing. A